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endovascular thrombectomy for acute ischemic stroke

Indications: - acute, moderate-to-severe ischemic stroke - stroke thrombectomy within 24 hours in patients with larger strokes [22] - tPA received within 4.5 hours of symptom onset - no advantage of tPA prior to thrombectomy [8] - occlusion of internal carotid artery or proximal middle cerebral artery [3,4,6] - no permanent damage in over half the brain on the affected side, according to CT imaging - no significant disability prior to stroke - age >= 18 years [6] - up to 24 hours after symptom onset# [11] - within 6-16 hours of anterior-circulation large-vessel occlusion [15] - within 24 hours for patients with large vessel occlusion, neurologic deficit, & small radiographically evident ischemic changes [7] - outside 24 hours, confers better functional independence but with increased risk of symptomatic intracranial hemorrhage [20] * benefit has not been established in randomized clinical trials [7] (MKSAP17) may no longer be so [11,12] * improves functional outcomes & quality of life [9] - benefits sustained for at least 2 years [9] # [12] describes 1 of 2 trials cited in [11] Contraindications: - no better than medical management for basilar-artery occlusion [17] Procedure: - CT of the brain with perfusion imaging [2] - tPA received within 4.5 hours of symptom onset - no advantage of tPA prior to thrombectomy [8] - tenecteplase before thrombectomy superior to alteplase [14,15] - no advantage to omitting thrombolysis before endovascular thrombectomy [18] - endovascular placement of self-expanding stent that can retrieve blood clots & restore circulation within 6 hours after symptom onset [6] - procedure may be of benefit up to 24 hours after symptom onset [11] - aspiration-assisted stent retrieval* - aspiration thrombectomy* * aspiration does not require a catheter to pass through a clot, reducing risk of distal emboli during the procedure [2] Radiology: - of benefit 6-16 hours after symptom onset if on perfusion imaging, initial infarct size < 70 ml & volume ratio of ischemia to infarction is > 1.8 [12] - endovascular thrombectomy of benefit for large volume ischemic stroke with only non-contrast CT imaging [24] - perfusion imaging unnecessary for benefit [24] Management: - conventional blood pressure management: systolic BP target 140-180 mm Hg - intensive blood pressure lowering (systolic BP < 140 mm Hg) during the first 24 hours after successful reperfusion may be harmful [23] - control of systolic blood pressure to < 160 mm Hg after endovascular thrombectomy for ischemic stroke unlikely to be of benefit [19,21] (see ischemic stroke Management: section) Notes: - intracranial stent may be of benefit [1] - endovascular approaches not superior to tPA [2] - endovascular thrombectomy following tPA may improve neurologic outcomes [4] - endovascular thrombectomy 'alone without tPA' vs following tPA: neither inferiority nor noninferiority demonstrated [16] - as safe in the real world as is in clinical trials [13]

Related

ischemic stroke

General

arterial thrombectomy

References

  1. Brekenfeld C et al. Stent placement in acute cerebral artery occlusion: Use of a self-expandable intracranial stent for acute stroke treatment. Stroke 2009 Mar; 40:847. PMID: 19182080
  2. Physician's First Watch, Feb 7, 2013 Massachusetts Medical Society - Ciccone A et al Endovascular Treatment for Acute Ischemic Stroke. New Engl J Med. February 6, 2013 PMID: 23387822 http://www.nejm.org/doi/full/10.1056/NEJMoa1213701
  3. Berkhemer OA et al A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke. N Engl J Med. December 17, 2014 PMID: 25517348 http://www.nejm.org/doi/full/10.1056/NEJMoa1411587 - Hacke W Interventional Thrombectomy for Major Stroke - A Step in the Right Direction. N Engl J Med. December 17, 2014 PMID: 25517349 http://www.nejm.org/doi/full/10.1056/NEJMe1413346
  4. Goyal M et al Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke. N Engl J Med. February 11, 2015 PMID: 25671798 http://www.nejm.org/doi/full/10.1056/NEJMoa1414905 - Campbell BCV et al Endovascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection. N Engl J Med. February 11, 2015 PMID: 25671797 http://www.nejm.org/doi/full/10.1056/NEJMoa1414792 - Saver J, Goyal M, Bonafe A et al Primary Results. Soltaire FR With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke Nashville, TN. February 11, 2015 http://my.americanheart.org/idc/groups/ahamah-public/@wcm/@sop/@scon/documents/downloadable/ucm_471815.pdf
  5. Saver JL et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 2015 Apr 17; PMID: 25882376 http://www.nejm.org/doi/full/10.1056/NEJMoa1415061 - Jovin TG et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 2015 Apr 17 PMID: 25882510 http://www.nejm.org/doi/full/10.1056/NEJMoa1503780 - Furlan AJ. Endovascular therapy for stroke - it's about time. N Engl J Med 2015 Apr 17; PMID: 25882509 http://www.nejm.org/doi/full/10.1056/NEJMe1503217
  6. Powers WJ et al 2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment. Stroke. June 29, 2015 PMID: 26123479 http://stroke.ahajournals.org/content/early/2015/06/26/STR.0000000000000074
  7. Medical Knowledge Self Assessment Program (MKSAP) 17, 19 American College of Physicians, Philadelphia 2015, 2021
  8. Coutinho JM et al. Combined intravenous thrombolysis and thrombectomy vs thrombectomy alone for acute ischemic stroke: A pooled analysis of the SWIFT and STAR studies. JAMA Neurol 2017 Jan 9 PMID: 28097310
  9. van den Berg LA, Dijkgraaf MG, Berkhemer OA et al Two-Year Outcome after Endovascular Treatment for Acute Ischemic Stroke. N Engl J Med 2017; 376:1341-1349. April 6, 2017 PMID: 28379802 http://www.nejm.org/doi/full/10.1056/NEJMoa1612136
  10. Dippel DWJ Thrombectomy Options for Acute Ischemic Stroke. Which Way to Go? JAMA Neurol. Published online Jan 2, 2018. PMID: 29297050 https://jamanetwork.com/journals/jamaneurology/article-abstract/2666951
  11. Powers WJ, Rabinstein AA, Ackerson T et al 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018; Jan 24 PMID: 29367334 http://stroke.ahajournals.org/content/early/2018/01/23/STR.0000000000000158 - Furie KL, Jayaraman MV 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke. PMID: 29367335 http://stroke.ahajournals.org/content/early/2018/01/24/STROKEAHA.118.020176
  12. Albers GW, Marks MP, Kemp S et al Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. N Engl J Med. Jan 24, 2018 PMID: 29364767 http://www.nejm.org/doi/full/10.1056/NEJMoa1713973
  13. Jansen IGH et al Endovascular treatment for acute ischaemic stroke in routine clinical practice: prospective, observational cohort study (MR CLEAN Registry). BMJ 2018;360:k949 PMID: 29523557 Free PMC Article http://www.bmj.com/content/360/bmj.k949
  14. Campbell BCV, Mitchell PJ, Churilov L et al Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke. N Engl J Med 2018; 378:1573-1582 PMID: 29694815 http://www.nejm.org/doi/full/10.1056/NEJMoa1716405
  15. Powers WJ, Rabinstein AA, Ackerson T et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 Update to the 2018 guidelines for the early management of acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke 2019 Dec; 50:e344. PMID: 31662037 https://www.ahajournals.org/doi/10.1161/STR.0000000000000211
  16. Suzuki K, Matsumaru Y, Takeuchi M et al Effect of Mechanical Thrombectomy Without vs With Intravenous Thrombolysis on Functional Outcome Among Patients With Acute Ischemic Stroke. The SKIP Randomized Clinical Trial. JAMA. 2021;325(3):244-253 PMID: 33464334 https://jamanetwork.com/journals/jama/fullarticle/2775278
  17. Langezaal LCM, van der Hoeven EJRJ, Mont'Alverne FJA Endovascular Therapy for Stroke Due to Basilar-Artery Occlusion. N Engl J Med 2021; 384:1910-1920. May 20 PMID: 34010530 https://www.nejm.org/doi/full/10.1056/NEJMoa2030297
  18. LeCouffe NE, Kappelhof M, Treurniet KM et al. A randomized trial of intravenous alteplase before endovascular treatment for stroke. N Engl J Med 2021 Nov 11; 385:1833. PMID: 34758251 https://www.nejm.org/doi/10.1056/NEJMoa2107727
  19. Hughes S Intensive BP Lowering Harmful in Acute Ischemic Stroke: ENCHANTED2/MT. Medscape. Oct 28, 2022 https://www.medscape.com/viewarticle/983176 - Yang P, Song L, Zhang Y et al Intensive blood pressure control after endovascular thrombectomy for acute ischaemic stroke (ENCHANTED2/MT): a multicentre, open-label, blinded-endpoint, randomised controlled trial. Lancet. 2022. Oct 27. PMID: 36341753 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01882-7/fulltext
  20. Lou N Stroke Thrombectomy Beyond the 24-Hour Window: Study Keeps the Door Open. Researchers push the boundaries of how late is too late for intervention. MedPage Today December 27, 2022 https://www.medpagetoday.com/cardiology/strokes/102392 - Sarraj A, Kleinig TJ, Hassan AE et al Association of Endovascular Thrombectomy vs Medical Management With Functional and Safety Outcomes in Patients Treated Beyond 24 Hours of Last Known Well. The SELECT Late Study. JAMA Neurol. Published online December 27, 2022 PMID: 36574257 https://jamanetwork.com/journals/jamaneurology/fullarticle/2799619
  21. Lou N BEST-II Throws Cold Water on Already-Tepid BP Lowering After Stroke Thrombectomy. Trial did not show definite harm, but benefit is unlikely. MedPage Today February 10, 2023 https://www.medpagetoday.com/meetingcoverage/isc/103061
  22. Sarraj A et al. Trial of endovascular thrombectomy for large ischemic strokes. N Engl J Med 2023 Feb 10; [e-pub]. PMID: 36762865 https://www.nejm.org/doi/10.1056/NEJMoa2214403 - Huo X et al. Trial of endovascular therapy for acute ischemic stroke with large infarct. N Engl J Med 2023 Feb 10; [e-pub]. PMID: 36762852 https://www.nejm.org/doi/10.1056/NEJMoa2213379
  23. Nam HS, Kim YD, Heo J et al Intensive vs Conventional Blood Pressure Lowering After Endovascular Thrombectomy in Acute Ischemic StrokeThe OPTIMAL-BP Randomized Clinical Trial. JAMA. 2023;330(9):832-842. PMID: 37668619 https://jamanetwork.com/journals/jama/fullarticle/2808993
  24. Bendszus M et al. Endovascular thrombectomy for acute ischaemic stroke with established large infarct: Multicentre, open-label, randomised trial. Lancet 2023 Oct 11 PMID: 37837989 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)02032-9/fulltext